Adrian Wong does ANZICS 2018! #FOAMed #FOAMcc #POCUS #ANZICS

Jonny Wilkinson

8 years ago

Adrian’s Lecture Notes

Precision Resuscitation (Pinsky)

4 Questions

Identify when patient has inadequate blood/oxygen flow to tissues to meet their metabolic demand
Define if fluid will improve cardiac output – If they are not volume responsive, don’t give fluid!
Define the vasomotor tone – normal or decreased
Define if ventricle can handle demand without going into failure

Surrogate preload markers do not reflect ventricular volumes or volume responsiveness

Arterial Elastance defines gain in SV/Arterial pressure relation – PPV/SVV

Summary

Personalised medicine in sepsis (Gordon)

Why personalise?

We treat very heterogenous patients e.g. some cancer pts respond and others don’t
Risk stratify

What can you measure?

Intensivists staffing on the ICU (Gershengorn)

36.8% of US ICU pts cared for by intensivists in 1997

Intensivists add
- procedural skills
- clinical judgement
- ICU triage
- patient flow

Defining staffing by workload rather than by numbers

“Nurses are constantly staffed based on the number of patients they have to care for.”

What is the best ICU bed/ICU patients:Intensivist ratio?

Future

Develop and validate tools to measure workload; evaluate the impact of intensivists

Globalisation of Critical Care (Buchman)

The next wave of ‘globalisation’

Migration of medical professionals
Communication: asynchronous, on-demand and (near) synchronous
Education – SoMe and blurring distinctions among website and face-to-face presentations

Professional society collaborations e.g. 2001 International Sepsis Definitions Conference
Multinational companies/corporations selling their products

Barriers to globalisation

Resource limitation(s)
Licensure and credentialing
Customs, adaptations, norms

Muscle wasting (Phillips)

Older population in particular

Dose and timing of intake important

Older people need more protein compared to younger people

Leucine triggers

Whey protein better than casein at stimulating muscle synthesis

Protein requirement for older patientt on ICU

Problems

Insulin resistance
Loss of muscle
Anabolic resistance
Poor/lack of recovery
Prolonged weakness

What are the challenges of Sepsis-3 (Ku)

Biomarkers in Sepsis (Kuan)

Role

Diagnosis

Procalcitonin
Gene expression
MicroRNA

Prognosis

Presepsis
Gene expression
Pharmacogenomics

Challenges with biomarkers

Multisystem
Varying effect in pts
Cost and time
No gold standard in sepsis definition
Most biomarkers not yet tested properly

Early resuscitation in sepsis (Delaney)

Cardiovascular management in sepsis (Gordon)

TTM (Leong)

Post Cardiac Arrest Syndrome

Reperfusion – ROSC, Inflammation, mitochondrial damage

The need for a new paradigm in resuscitation post cardiac surgery (Levine)

ICU of the future (Tan)

Electronic records
SMART alarms
SMART pumps
A.I

Brain death and cardiac death – are there really two ways to die? (Kwek)

Code of practice for confirmation of death document here

Death diagnosis form here

I attach some interesting videos on the subject from the ODT website:

Epidemiology and identification of the organ donors (Pilcher)

DCD (D’Costa)

15% of deaths in ventilated patients are brain death
85% of deaths in ventilated patients are non-brain dead
Clinicians (alone) are poor at identifying potential DCD donor so opting for ROUTINE REFERRAL
As DCD referrals increases, the actual donation rate increases
Logistic support
- organ donor coordinators
- support/admin staff
Consider
- theatre availability
- retrieval team availability